CLINICAL HISTORY:

Signs and symptoms:  Intensely pruritic lesions.

Previous Treatment:  None.

Other information:  He started taking Lipitor, Metformin, and Lotrel four months prior to onset of lesions.

PHYSICAL EXAM:

Evaluation of the bilateral axillae reveals two well demarcated erythematous plaques with a pinkish sheen. There is no scale present. The inguinal region bilaterally as well as the gluteal folds reveal similar lesions; however, much larger. No excoriations or signs of secondary infection are present.

Axillary Vault

Close-Up of Axilla

Inguinal Fold

Gluteal Fold

LABORATORY TESTS:

The CBC and CMP were within acceptable limits. ANA was found to be negative and the RPR was non-reactive.

DERMATOHISTOPATHOLOGY:

PAS stain negative for fungi.

H & E

H & E

DIFFERENTIAL DIAGNOSIS:

1.   Contact Dermatitis
2.   Tinea
3.   Mycosis Fungoides
4.   Inverse Psoriasis
5.   Drug Eruption

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Inverse Psoriasis

DISCUSSION:

Inverse or flexural psoriasis is characterized by shiny, pink to red, sharply demarcated thin plaques. There is much less scale that in untreated chronic plaque type psoriasis. Often a central fissure is seen. The most common sites of involvement are the axillae, the inguinal crease, the intergluteal cleft, the inframammary region and the retroauricular folds. Localized fungal and/or bacterial infections can be a trigger for this condition.

TREATMENT:

Patients with inverse psoriasis develop lesions in the axillae, between the buttocks, on the medial aspects of the thighs, and the umbilicus. These sites are easily treated with mild topical corticosteriods, but are more susceptible to corticosteroid side effects such as atrophy and the formation of striae. Consequently, nonsteroidal treatments are often utilized. Calcipotriene can be irritating on intertriginous sites but is nevertheless effective. Some have advocated diluting calcipotriene with petrolatum in equal amounts to minimize irritation. If irritation does not develop, the amount of petrolatum added can be reduced.

According to a 2004 study, Pimecrolimus cream 1% is an effective treatment for inverse psoriasis with a rapid onset of action; it is safe and well-tolerated in both adults and children.

Tazarotene can be used on the face, but is usually too irritating to use in the axillae or groin. Tars and anthralin are likewise irritating in intertriginous sites.

REFERENCES:

1. Berger, Elston, James. (2006) Andrews’ Diseases of the Skin. Philadelphia, PA.
Elsevier
2. Bolognia JL, Jorizzo JL, Rapini RP, et. al. (2003) Dermatology. Spain: Mosby
3. Lebwohl , Heymann, Jones, Coulson. (2005) Treatment of Skin Disease: Comprehensive Therapeutic Strategies, Mosby
4. Pimecrolimus cream 1% in the treatment of intertriginous psoriasis: A double-blind, randomized study
Gribetz C, Ling M, Lebwohl M, Pariser D, Draelos Z, Gottlieb AB, Zaias N, Chen DM, Parneix-Spake A, Hultsch T, Menter A
Journal of the American Academy of Dermatology- 2004 11 (Vol. 51, Issue 5)
5. Topical tacrolimus in the treatment of inverse psoriasis in children
Steele JA, Choi C, Kwong PC
Journal of the American Academy of Dermatology- 2005 10 (Vol. 53, Issue 4)

Additional Comment:

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